The Value Of Close Calls In Improving Patient Safety
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The Value of Close Calls in Improving Patient Safety by Joint Commission Resources, Inc Pdf
Because close calls, often termed near misses, don't raise the same concerns about malpractice liability and may be less emotionally charged than errors that cause serious harm, they are a unique source of learning for individuals and organizations striving to keep patients safe. This book tells how to take advantage of these lessons to prevent today's close call from turning into tomorrow's catastrophic event. Special Features: * Foreword by human error expert James Reason, Ph.D. * Authoritative tutorials on what the literature tells us about the concept of close calls and their identification, relationship with errors, and use in assessing and improving the safety and reliability of health care. * 15 detailed case studies from a variety of clinical disciplines and specialties to show how health care organizations use close calls to identify and solve patient safety problems
Institute of Medicine,Committee on Quality of Health Care in America
Author : Institute of Medicine,Committee on Quality of Health Care in America Publisher : National Academies Press Page : 312 pages File Size : 50,9 Mb Release : 2000-03-01 Category : Medical ISBN : 9780309068376
To Err Is Human by Institute of Medicine,Committee on Quality of Health Care in America Pdf
Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine
Author : Ronda Hughes Publisher : Department of Health and Human Services Page : 592 pages File Size : 45,6 Mb Release : 2008 Category : Medical ISBN : IOWA:31858055672798
"Nurses play a vital role in improving the safety and quality of patient car -- not only in the hospital or ambulatory treatment facility, but also of community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes. To address this need, the Agency for Healthcare Research and Quality (AHRQ), with additional funding from the Robert Wood Johnson Foundation, has prepared this comprehensive, 1,400-page, handbook for nurses on patient safety and quality -- Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043)." - online AHRQ blurb, http://www.ahrq.gov/qual/nurseshdbk/
Principles of Perioperative Safety and Efficiency by Jamal J. Hoballah,Haytham M. A. Kaafarani,Georgios Tsoulfas Pdf
Perioperative safety continues to be a global challenge. It is estimated that approximately 200 million surgical procedures are performed annually worldwide, and despite various national and global safety initiatives, perioperative adverse event rates remain alarmingly high. Although hospitals and governmental agencies impose safety standards and certification by organizations such as the Joint Commission, which can address issues of perioperative safety, many hospitals in developed, developing or underdeveloped countries lack the resources or knowhow to decrease perioperative adverse events. There is a great opportunity for improving perioperative safety worldwide especially in underdeveloped or developing countries. Filling a gap in the literature, this book teaches healthcare providers the basic principles of perioperative safety and efficiency, including checklists and processes to reduce adverse events. Presented here are the basics of intraoperative monitoring and safety measures to reduce patient adverse events, including wrong site surgery, electric burn injury, deep venous thrombosis, surgical site infection and foreign body retention. Emphasis is given toward developing awareness into measures preventing occupational injuries, such as sharp injury, radiation exposure, laser exposure and smoke hazard. It also addresses dealing and reporting adverse events and disruptive behaviors in the operating rooms as well as new measures for enhanced recovery following surgery and anesthesia. Principles of Perioperative Safety and Efficiency is a valuable resource and reference for all operating room personnel including surgeons, surgical residents, medical students and nurses.
Institute of Medicine,Board on Health Care Services,Committee on the Work Environment for Nurses and Patient Safety
Author : Institute of Medicine,Board on Health Care Services,Committee on the Work Environment for Nurses and Patient Safety Publisher : National Academies Press Page : 485 pages File Size : 45,6 Mb Release : 2004-03-27 Category : Medical ISBN : 9780309187367
Keeping Patients Safe by Institute of Medicine,Board on Health Care Services,Committee on the Work Environment for Nurses and Patient Safety Pdf
Building on the revolutionary Institute of Medicine reports To Err is Human and Crossing the Quality Chasm, Keeping Patients Safe lays out guidelines for improving patient safety by changing nurses' working conditions and demands. Licensed nurses and unlicensed nursing assistants are critical participants in our national effort to protect patients from health care errors. The nature of the activities nurses typically perform â€" monitoring patients, educating home caretakers, performing treatments, and rescuing patients who are in crisis â€" provides an indispensable resource in detecting and remedying error-producing defects in the U.S. health care system. During the past two decades, substantial changes have been made in the organization and delivery of health care â€" and consequently in the job description and work environment of nurses. As patients are increasingly cared for as outpatients, nurses in hospitals and nursing homes deal with greater severity of illness. Problems in management practices, employee deployment, work and workspace design, and the basic safety culture of health care organizations place patients at further risk. This newest edition in the groundbreaking Institute of Medicine Quality Chasm series discusses the key aspects of the work environment for nurses and reviews the potential improvements in working conditions that are likely to have an impact on patient safety.
Handbook of Human Factors and Ergonomics in Health Care and Patient Safety, Second Edition by Pascale Carayon Pdf
The first edition of Handbook of Human Factors and Ergonomics in Health Care and Patient Safety took the medical and ergonomics communities by storm with in-depth coverage of human factors and ergonomics research, concepts, theories, models, methods, and interventions and how they can be applied in health care. Other books focus on particular human factors and ergonomics issues such as human error or design of medical devices or a specific application such as emergency medicine. This book draws on both areas to provide a compendium of human factors and ergonomics issues relevant to health care and patient safety. The second edition takes a more practical approach with coverage of methods, interventions, and applications and a greater range of domains such as medication safety, surgery, anesthesia, and infection prevention. New topics include: work schedules error recovery telemedicine workflow analysis simulation health information technology development and design patient safety management Reflecting developments and advances in the five years since the first edition, the book explores medical technology and telemedicine and puts a special emphasis on the contributions of human factors and ergonomics to the improvement of patient safety and quality of care. In order to take patient safety to the next level, collaboration between human factors professionals and health care providers must occur. This book brings both groups closer to achieving that goal.
Institute of Medicine,Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety
Author : Institute of Medicine,Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety Publisher : National Academies Press Page : 323 pages File Size : 40,6 Mb Release : 2009-05-27 Category : Medical ISBN : 9780309127769
Resident Duty Hours by Institute of Medicine,Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety Pdf
Medical residents in hospitals are often required to be on duty for long hours. In 2003 the organization overseeing graduate medical education adopted common program requirements to restrict resident workweeks, including limits to an average of 80 hours over 4 weeks and the longest consecutive period of work to 30 hours in order to protect patients and residents from unsafe conditions resulting from excessive fatigue. Resident Duty Hours provides a timely examination of how those requirements were implemented and their impact on safety, education, and the training institutions. An in-depth review of the evidence on sleep and human performance indicated a need to increase opportunities for sleep during residency training to prevent acute and chronic sleep deprivation and minimize the risk of fatigue-related errors. In addition to recommending opportunities for on-duty sleep during long duty periods and breaks for sleep of appropriate lengths between work periods, the committee also recommends enhancements of supervision, appropriate workload, and changes in the work environment to improve conditions for safety and learning. All residents, medical educators, those involved with academic training institutions, specialty societies, professional groups, and consumer/patient safety organizations will find this book useful to advocate for an improved culture of safety.
Health Care Errors and Patient Safety by Brian Hurwitz,Aziz Sheikh Pdf
The detection, reporting, measurement, and minimization of medical errors and harms is now a core requirement in clinical organizations throughout developed societies. This book focuses on this major new area in health care. It explores the nature of medical error, its incidence in different health care settings, and strategies for minimizing errors and their harmful consequences to patients. Written by leading authorities, it discusses the practical issues involved in reducing errors in health care - for the clinician, the health policy adviser, and ethical and legal health professionals.
Drawing on extensive and detailed fieldwork within airlines-an industry that pioneered near-miss analysis- this book develops a clear set of practical implications and theoretical propositions regarding how all organizations can learn from 'near-miss' events and better manage risk and resilience.
Governance Ethics in Healthcare Organizations by Gerard Magill,Lawrence Prybil Pdf
Drawing on the findings of a series of empirical studies undertaken with boards of directors and CEOs in the United States, this groundbreaking book develops a new paradigm to provide a structured analysis of ethical healthcare governance. Governance Ethics in Healthcare Organizations begins by presenting a clear framework for ethical analysis, designed around basic features of ethics – who we are, how we function, and what we do – before discussing the paradigm in relation to clinical, organizational and professional ethics. It goes on to apply this framework in areas that are pivotal for effective governance in healthcare: oversight structures for trustees and executives, community benefit, community health, patient care, patient safety and conflicted collaborative arrangements. This book is an important read for all those interested in healthcare management, corporate governance and healthcare ethics, including academics, students and practitioners.
Principles of Risk Management and Patient Safety by Barbara J. Youngberg Pdf
Principles of Risk Management and Patient Safety identifies changes in the industry and describes how these changes have influenced the functions of risk management in all aspects of healthcare. The book is divided into four sections. The first section describes the current state of the healthcare industry and looks at the importance of risk management and the emergence of patient safety. It also explores the importance of working with other sectors of the health care industry such as the pharmaceutical and device manufacturers. Important Notice: The digital edition of this book is missing some of the images or content found in the physical edition.
Closing Death's Door by Michael J. Saks,Stephan Landsman Pdf
After heart disease and cancer, the third leading cause of death in the United States is iatrogenic injury (avoidable injury or infection caused by a healer). Research suggests that avoidable errors claim several hundred thousand lives every year. The principal economic counterforce to such errors, malpractice litigation, has never been a particularly effective deterrent for a host of reasons, with fewer than 3% of negligently injured patients (or their families) receiving any compensation from a doctor or hospital's insurer. Closing Death's Door brings the psychology of decision making together with the law to explore ways to improve patient safety and reduce iatrogenic injury, when neither the healthcare industry itself nor the legal system has made a substantial dent in the problem. Beginning with an unflinching introduction to the problem of patient safety, the authors go on to define iatrogenic injury and its scope, shedding light on the culture and structure of a healthcare industry that has failed to effectively address the problem-and indeed that has influenced legislation to weaken existing legal protections and impede the adoption of potentially promising reforms. Examining the weak points in existing systems with an eye to using law to more effectively bring about improvement, the authors conclude by offering a set of ideas intended to start a conversation that will lead to new legal policies that lower the risk of harm to patients. Closing Death's Door is brought to vivid life by the stories of individuals and groups that have played leading roles in the nation's struggle with iatrogenic injury, and is essential reading for medical and legal professionals, as well as lawmakers and laypeople with an interest in healthcare policy.
Author : Annegret Hannawa,Anne Wendt,Lisa Day Publisher : Walter de Gruyter GmbH & Co KG Page : 271 pages File Size : 51,7 Mb Release : 2017-12-18 Category : Medical ISBN : 9783110454505
New Horizons in Patient Safety: Safe Communication by Annegret Hannawa,Anne Wendt,Lisa Day Pdf
This case studies book is an indispensable resource for educators, students, and practitioners of nursing. It is innovative in its application of lessons from the communication sciences to common challenges in the delivery of safe patient care. The authors apply basic tenets of human communication to the context of nursing to provide a foundation for practices that can advance the safety and quality of care. The cases, which describe "close calls" and adverse events, are organized along the continuum of healthcare delivery, providing quick access to solutions in commonly encountered care situations. Each case is accompanied by a discussion of how skillful communication can be key to preventing and recovering from errors and adverse events. Thought-provoking discussion questions and references for further reading make this book a valuable reference for nursing educators, students, and practitioners across the world.
